Every house painting job looks good from a distance

March 1, 2007
One of my father’s favorite expressions is “If we step back far enough anything can look OK. But on closer examination, the truth emerges.”

by Richard Mounce, DDS

One of my father’s favorite expressions is “If we step back far enough, anything can look OK. But on closer examination, the truth emerges.”

Recently, a friend of the family had endodontic treatment. As the story was related to me, a lower third molar had been moved previously into the position of the missing second, and was slightly tipped mesially. Despite preexisting clear symptoms of irreversible pulpitis, the patient was initially scheduled for a crown preparation. A carious exposure occurred and the tooth was referred for endodontic treatment to another general practitioner within the same group “who does a lot of root canals.”

The first visit lasted approximately one and one-half hours. The next day, the patient was seen for a reported three-hour plus visit to perform the root canal. Anesthesia difficulties were reported at both sessions, and no rubber dam was used for the root canal. Also, a surgical operating microscope was not used for visualization. The patient reported that the crown impression was taken immediately after the root canal at the second visit. Severe pain after the second visit occurred, which was accompanied by trismus.

I am not a big fan of cynics, critics, and Monday morning quarterbacks. While I did not see the procedure (of which much comment could be made), I have a genuine concern about the lack of a rubber dam. This approach is less than the legal standard of care and, in my estimation, predisposes the treatment to failure. In 2007, the rubber dam might not just be thought of as the legal standard of care but the clinical - and by extension - moral one as well.

There simply is no substitute. If the patient cannot tolerate, or refuses the rubber dam, the tooth should be removed - without exception. The implications and complications of attempting root canal treatment on any tooth without one cannot be ignored.

While a clinician may try to justify not using a rubber dam, in 15 years of specialty practice, I have never seen a tooth whose elimination of using the rubber dam was advisable nor have I ever been tempted to work without it. It is rare that a tooth might be accessed without a rubber dam because of rotation. But from the first opening of the canal, a rubber dam is indicated.

The following are several concerns that I have when talking about treatment without a rubber dam.This treatment:

  • risks irrigant aspiration or ingestion
  • provides no visual control over the tooth and operating field
  • makes locating canals difficult at best
  • makes tactile control over the files used, both hand and rotary nickel titanium, difficult if not nearly impossible to master
  • encourages iatrogenic events of all types as control during the access is simply not what it could be if a rubber dam were used
  • encourages a lack of irrigation due to the risk mentioned previously
  • makes proper sepsis difficult, if not nearly impossible, in that salivary contamination of the canals is likely

In addition, a third molar - from a technical point of view - is one of the most challenging teeth in the mouth. Attempting it without a rubber dam makes management of it, without the needed control of the site, problematic. This is true even with the most compliant patients. Compounded by a lack of visualization, treating a third molar (or any tooth for that matter) without a rubber dam is not a recipe for a predictable outcome.

Referral was likely the best option. I cannot envision a clinician who has a patient’s best interest in mind, subjecting someone to some four and one-half hours of treatment in two days. This is especially true when, in this case, there was no overriding reason to do so since the patient was not leaving for an extended period of time (e.g., on a trip).

Also, how is it an advisable clinical practice to take the impression on the same day as completion of a third molar root canal? What trauma was done to the patient’s TMJ? How reliable will the impression and bite registration be? Was this motivated simply by the need for production?

If this root canal were viewed far enough away, it might look acceptable on a radiograph. But with the risk factors given, this clinically challenging situation - through no fault of the patient’s because he or she was following the advice of the dentist - carries a preventable, higher, and lamentable probability of failure.

I welcome your questions and feedback.

Dr. Richard Mounce lectures globally and is widely published. He is in private practice in endodontics in Portland, Ore. Among other appointments, he is the endodontic consultant for the Belau National Hospital Dental Clinic in the Republic of Palau, Korror, Palau (Micronesia). He can be reached at [email protected].

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